Payers often have concerns that the Texas prompt pay statutes and rules require them to pay claims they suspect may be fraudulent.
The TDI Fraud Unit may investigate and/or refer such matters to the appropriate authority, including the Texas Medical Board (TMB), other state agencies regulating healing art professions, a district attorney's office, the Office of the Attorney General or the federal government.
Carriers may seek reimbursement of overpayment pursuant to Subsection (f) 28 Texas Administrative Code (TAC) §21.2818 in the case of fraud or material misrepresentation. Recovery efforts under such circumstances are not subject to the 180-day deadline that is otherwise applicable.
TDI encourages payers to report suspected fraudulent practices to the TDI Fraud Unit so that TDI can take appropriate action. A payer may decide to deny a claim it determines to be fraudulent after undertaking a reasonable investigation as required by Texas Insurance Code (TIC) §541.060. In such case, as with any other suspected insurance fraud, payers are reminded that TIC §701.051 states "Not later than the 30th day after the date the person makes the determination or reasonably suspects that a fraudulent insurance act has been or is about to be committed in this state, the person shall report the information in writing to the insurance fraud unit...and may also report the information to another authorized governmental agency.”